Ethical Decision Making

Jonsen and colleagues’ (2022) Four Topics Method for ethical analysis is a practical approach for nurses and other healthcare professionals. The nurse or team begins with relevant facts about a particular case and moves toward a resolution through a structured analysis. In healthcare settings, ethics committees often resolve ethical problems and answer ethical questions by using a case-based, or bottom-up, inductive, casuistry approach. The Four Topics Method, sometimes called the Four Box Approach (Table 2-1) is found in the book Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine (Jonsen et al., 2022).

TABLE 2-1 Four Topics Method for Analysis of Clinical Ethics Cases

Medical Indications:
The Principles of Beneficence and Nonmaleficence.

What is the patient’s medical problem? Is the problem acute? Chronic? Critical? Reversible? Emergent? Terminal?
What are the goals of treatment?
In what circumstances are medical treatments not indicated?
What are the probabilities of success of various treatment options?
In sum, how can this patient be benefited by medical and nursing care, and how can harm be avoided?

Preferences of Patient:
The Principle of Respect for Autonomy

Has the patient been informed of benefits and risks of diagnostic and treatment recommendations, understood this information, and given consent?
Is the patient mentally capable, and legally competent, and is there evidence of incapacity?
If mentally capable, what preferences about treatment is the patient stating?
If incapacitated, has the patient expressed prior preferences?
Who is the appropriate surrogate to make decisions for the incapacitated patient? What standards should govern the surrogate’s decisions?
Is the patient unwilling or unable to cooperate with medical treatment? If so, why?

Quality of Life:
The Principles of Beneficence and Nonmaleficence and Respect for Autonomy

What are the prospects, with or without treatment, for a return to normal life and what physical, mental, and social deficits might the patient experience even if treatment succeeds?
On what grounds can anyone judge that some quality of life would be undesirable for a patient who cannot make or express such a judgment?
Are there biases that might prejudice the provider’s evaluation of the patient’s quality of life?
What ethical issues arise concerning improving or enhancing a patient’s quality of life?
Do quality-of-life assessments raise any questions that might contribute to a change of treatment plan, such as forgoing life-sustaining treatment?
Are there plans to provide pain relief and provide comfort after a decision has been made to forgo life-sustaining interventions?
Is medically assisted dying ethically or legally permissible?
What is the legal and ethical status of suicide?

Contextual Features:
The Principles of Justice and Fairness.
Are there professional, interprofessional, or business interests that might create conflicts of interest in the clinical treatment of patients?
Are there parties other than clinician and patient, such as family members, who have a legitimate interest in clinical decisions?
What are the limits imposed on patient confidentiality by the legitimate interests of third parties?
Are there financial factors that create conflicts of interest in clinical decisions?
Are there problems of allocation of resources that affect clinical decisions?
Are there religious factors that might influence clinical decisions?
What are the legal issues that might affect clinical decisions?
Are there considerations of clinical research and medical education that affect clinical decisions?
Are there considerations of public health and safety that affect clinical decisions?
Does institutional affiliation create conflicts of interest that might influence clinical decisions?

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